Maternity Care in the United States Remains Separate and Unequal

This past weekend, birth workers convened in Atlanta for the first Black Maternal Health Conference and Training Institute. The Institute brought together doulas, midwives, nurses, doctors, public health advocates, researchers and mothers with a singular commitment to address a national crisis: Black mothers are three to four times as likely to die from pregnancy complications as White mothers.

The Black Mamas Matter Alliance convened the Institute, and advisory committee members noted that Congress has introduced 20 different bills this session to address maternal mortality. However, these bills do not sufficiently address a fundament problem: racism, not race, is a key contributor disparities in maternal mortality. And after almost two decades as a practice obstetrician, I have come to appreciate that as a health care provider, I am complicit: I practice in a system that is designed to deliver unequal care. This unequal care perpetuates structural and institutionalized racism – the “differential access to the goods, services, and opportunities of society by race” for Black, Indigenous and other People of Color.

Consider prenatal care. During pregnancy, 2 in 3 White pregnant individuals have private insurance, while 2 in 3 Black pregnant individuals have Medicaid. This difference in income and insurance coverage is the legacy of racist policies such as redlining and segregation, that have caused a yawning gap in wealth between Black and White Americans. As Jessica Roach noted in her opening plenary, these racist policies are the underlying cause of adverse social determinants of health, such as unstable housing, lack of transportation, food insecurity and poverty, that disproportionately impact people of color. And yet, despite the complex challenges facing patients living in poverty, patients with Medicaid are typically seen by doctors-in-training, while privately insured patients receive care from board-certified physicians. Why is it acceptable for patients to receive care from inexperienced trainees? If trainees are well-supervised and just as capable as fully trained doctors, then both private and publicly insured patients would be seen by trainees, with faculty supervision. And if care by a fully-trained physician is superior, would a just society not demand that its highest-risk patients see our most experienced providers?

In part, these differences in care provided are about money – specifically, the enormous gap between Medicaid and private payer reimbursement. In North Carolina, Medicaid pays providers just $1327.53 for global OB care, which includes up to 14 prenatal visits, delivery, and postpartum care. For the same services, private insurance where I practice reimburses more than $2800. Why is it considered acceptable to pay half as much for a Medicaid patient?

The diminished value placed on the reproduction of people of color is pervasive. Consider a recent video celebrating the successes of a quality collaborative in a South Carolina: A professionally-produced film describes five initiatives, set against soaring music and soft-focus images of moms and babies. In a state where 28.8% of birthing women are Black, there were only three Black women in the 10-minute video – two clinicians and a patient, all in a segment on postpartum Long-Acting Reversible Contraception (LARC). A Black mother describes how getting a Nexplanon implant immediately after birth enabled her to get a driver’s license, enroll in a training program, and get a better job to support her family. It was an uplifting argument for access to contraception – access that is an essential component of reproductive autonomy. And, as the only image of a Black mother in a state where 16,000 Black women give birth each year, it was an insidious reinforcement of the narrative that if Black women could just keep their legs crossed, they could pull themselves out of poverty.

I shudder to think how many times in my 17 years of obstetrics practice I have high-fived a colleague for “talking her into Nexplanon.” It is tidy to think that if we can just control the fertility of marginalized people, they can transcend institutionalized racism and realize the American Dream -- as though a birth control implant will somehow compensate for the fact that a Black mother earns $0.51 for every dollar earned by a non-Hispanic White father. We must recognize that coercive contraception does not correct institutional racism – it perpetuates it.

We can name and dismantle the structural and institutional racism impacting our healthcare practices, policies and systems. We can demand payment schedules that provide equitable reimbursement for care of marginalized people, including coverage for doulas and other birth workers. We can ensure that patients with the most complex needs are seen by the most experienced medical providers. We can mentor diverse trainees and commit to foster communities that support them to become part of a workforce that looks like the patients we serve. We can tailor care to the needs of each pregnant and parenting family. And every day, we can own our implicit biases and practice cultural humility. Before we enter a patient’s room, we can pause and prepare to see them as an individual, listening more than we speak and recognizing their unique strengths and vulnerabilities. As Ancient Song doula Chanel Porchia-Albert put it, “Be humble. That’s it.”

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